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• • RECEIVED MONITORING SYSTEM CERTIFICATION DEC 0 12017 P"or Use 4v,411 Jurisdictions It,'ithin the .3jote cCalifornia Authority Cited: Chapter 6.7. Health and Sqfeq'Code; Chapter 16, Division 3, Tide 23, California Code olRegulanons This form must be used to document testing and servicing of monitoring equipment. A separate certification-,, report �niu -afl EALTH system control panel by the technician who performs the vvork. A copy of this form must be provided to the tank system owner/opertPc� tor _PAPTW_ T must submit a copy ofthis form to the local agency regulating UST sN I sterns within 30 days of test date. A. General Information Facility Name: Arco AmPm- Victor Rd County: San Joaquin ------- ....... Site Address: 880 Victor Rd Cite: Lodi Contact Phone 209-369-0153 Facility Contact Person: Karan Make/Model of Monitoring System: TLS 305 Date ofTesting/Servicing: 9/14/2017 P T. ---*-- __4 ul ......... MEEWM� Tank n k 87 Tank k I D: 9 1 In -Tank (jauging Probe. I ank Gauging - Model. rnaE Probe. I n -Tank Gauging Probe, k GaugingP' i ` o Model: mag Model M o ' FID: 1 , _" Annular Space or Vault Sensor. Model: 301 _,cosor. .1, " .Annular Space or Vault Sensor. , , ' "'O'Va S P' Model: Model: 301 Piping Surnp / Trench Sensor(s) Model: 208 Piping Sump / I ren h Sensor(s). P. in So Trench E] Piping Sump /Trench Sensor(s). Model Model: Fill Sump Sensor(s). 0 0 .1 1 Sump S, Model: 0 Fill Sump Sersor(s), Model: Mechanical Line Leak Detector. Model: LD 2000 Z Mechanical Line Leak Detector. Model. LD 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Flapper Tank- Overfill / High -Level Sensor. 0 Other (specify equipment type and Model: Flapper model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Tank ID: DSL Tank ID: ED In -Tank Gauging Probe. Model: mag 0 In -lank Gauging Probe Model. JE Annular Space or Vault Sensor. Model: 420 0 .Annular Space or Vault Sensor. Model: 23 Piping Sump / Trench Sensor(s). Model: 208 E] Piping Sump ."Trench Sensor(s). Model: El Fill Sump Sensor(s)- Modem. ❑ Fill SUMP SCFISK(S). Model: Z Mechanical Line Leak Detector. Model: LD 2000 C] Mechanical Line Leak Detector. Model: C1 Electronic Line Leak Detector. Model: E3 Electronic Line Leak Detector. Model Tank Overfill / High -Level Sensor. Model: Flapeer ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Tank Overfill I High -Level Sensor. Model: ❑ Other (specify equipment tvpc and model in Section E on Page 2). Dispenser ID: 1/2 Dispenser ID: 314 Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s) Model: 208 Shear Valve(s). Shear Valve(s). 171 Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s)._ Dispenser ID: 510 Dispenstr ID: 718 Z Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 Shear Valve(s). Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: 9/10 Dispenser ID: Dispenser El Dispenser Containment Sensor(s), Model: 208 ns -r() El Dispenser containment Sensor(s), Model Model: Shear Valve(s). V, ❑'Shear Valve(s). v� Dispenser Containment Float(s) and Chain(s). e Chain(s). nd Cha n Dispenser Containment Float(s) and Chain(s). Check the appropriate boxes to indicate speculic equiPine", 1115I)ccirutIrl .'-- C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that ajrpr): S System set-up El Alarm history report Technician Name (print): Rhome Desbiens Signature: Certification A22883 License No.: 433159 Testing Company Name: B. Z. Service Station Maintenance Phone No.: (916) 37I__-2380 Site 1041 Triangle Court West Sacramento, CA 95605 Date of Testing/Servicing: 9/14/2017 Monitoring Certification Test Report 1 of